SHCR Summer 2025 Camp Participation Waiver And Release Form

Participation Waiver And Release Form

Shepherd's Hill at the Crossroads - Not to Be Served, But to Serve - Summer 2025
Camper's Name & Information
Participant Name*

First NameLast Name
DOB*

MonthDayYear
Date
Please let us know about any issues that pertain to this individual and explain below:
Including but not limited to: Recent Injury or illness, Chronic or Recurring Illness, Frequent headaches, Glasses or contacts, Seizures, Joint (elbows, knees) problems, Orthodontic appliance, Skin problems (rash, acne eczema), Diabetes, Asthma, Sleepwalking, Autism, Sensory issues, ADD/ADHD, Behavioral issues, emotional difficulties (depression, anxiety, etc.)
Medications
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Please clearly indicate with the medications the time of day and amount of medications to be taken. Medications will be collected, stored and distributed by staff at the scheduled time as indicated below. It is helpful is all medications are packed in a zip lock bag, in an easy to access area of luggage, as it is turned into the office upon arrival.
I authorize staff at Shepherd’s Hill at the Crossroads to administer the following over-the-counter medications according to label instruction (please select any of the following):*

TylenolIbuprofenBenadrylCough Drop/Throat LozengeNONE
Please list any Medication allergies or any Food allergies or any Other allergies.
Are there any restrictions to activities or other additional information that we should know about this camper?
I need to include more children on this form
Include all your participating children on one form.

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian Secondary Phone Number
Please enter a valid phone number.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to child(ren)*
Equine Activity Release, Waiver of Liability, Hold Harmless & Indemnification Agreement

Please read this agreement carefully and completely before agreeing to it. Your child(ren) will not be able to be around the horses for lead rides, trail rides, or horse camps without your initials on this waiver.

ND Law States…an equine activity sponsor or an equine professional is not liable for an injury to or the death of a participant engaged in an equine activity . . . no participant or participant’s representative may maintain an action against or recover from an equine activity sponsor or an equine professional for an injury to or the death of a participant engaged in an equine activity. By signing this waiver, I acknowledge that I am taking full liability upon myself while participating in the horse program at Shepherd’s Hill at the Crossroads. I understand that the horses used by Shepherd’s Hill at the Crossroads are well-broke riding horses, and that even well-broke horses can be unpredictable. I also agree not to hold Shepherd’s Hill at the Crossroads, its wrangler(s) or horse provider(s) responsible for injury or death sustained in activities in the Shepherd’s Hill at the Crossroads Horse Program.
Initial here to show that you understand the Equine Activity Liability laws of the State of North Dakota.
I grant my consent to Shepherd’s Hill at the Crossroads and its representatives, including archery instructors, to furnish my child(ren) with archery equipment while participating in supervised programming. I understand that instructions for the safe and proper use of range and target sports equipment will be provided. Initials*
I permit the camp to administer prescribed medications as instructed, provide first aid, and seek emergency medical treatment if deemed necessary. In the event I cannot be reached in an emergency, I authorize Shepherd’s Hill at the Crossroads to contact the emergency contact person and give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person(s) named herein. Initials*
This Participation Waiver And Release Form is correct and complete as far as I know. The person(s) herein described has/have permission to engage in all camp activities except as noted.

I certify that I am the parent with full parental rights or the legal guardian of this child or these children named herein. I understand that Shepherd’s Hill at the Crossroads or its representatives will keep and maintain this document. I further understand that any modification of this form will result in it not being accepted by Shepherd’s Hill at the Crossroads or its representatives.
Parent/Guardian Signature*

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Participation Waiver And Release Form

Camper's Name & Information

Additional Camper's Information

Parent/Guardian Information